November, 2004

Position Statement On the "Magnet Recognition Program for Nursing Services in Hospitals" and Other Consultant-Driven Quality Improvement Projects that Claim to Improve Care

MNA opposes the latest industry strategy to avoid safe RN-to-patient ratios

In the wake of an onslaught of studies and reports detailing deplorable nursing care in hospitals and a massive exodus of nurses who are refusing to work under such conditions, and in the face of a growing movement by nurses, the public and legislators for the imposition of mandated RN-to-patient ratios to correct these deficiencies, the hospital industry has increasingly turned to a voluntary process of accreditation and validation of its nursing programs (similar to that provided for hospitals by the Joint Commission on the Accreditation of Health Care Organizations). This designation, known as "Magnet Recognition" has been around for years, but more recently has been embraced by hospital and nursing administrators as a means of boosting public confidence in their nursing care, improving retention of its nursing staff and, perhaps more importantly, increasing its reimbursement for services by the federal government and private insurers.

The Massachusetts Nurses Association Board of Directors, which has evaluated this program in detail, today issued a position statement opposing this and other consultant-driven quality improvement projects that claim to improve care yet fail to guarantee safe staffing levels and adequate working conditions for nurses. The MNA views the Magnet process as a pure marketing ploy that trades on the public's trust in nurses as a vehicle for burnishing the hospital's image. The MNA believes true quality of care can only be achieved when nurses and the public are guaranteed minimum, safe RN-to-patient ratios as a matter of law, and when nurses are provided with the legally protected right to influence and improve their working conditions.

Full Text of Position Statement

Background
In recent years, registered nurses, health care providers, citizens, and policy makers have become increasingly concerned with the quality and safety of nursing care in America's hospitals. A number of influential reports and studies show a dramatic rise in medical errors, poor patient outcomes and an alarming number of preventable patient deaths directly attributable to: inadequate RN staffing levels; poor RN-to-patient ratios; dangerous working conditions, such as the use of mandatory overtime; and dangerous administrative practices, such as utilizing unlicensed personnel to provide care that only RNs should provide, and floating of nurses to units where they are ill-prepared to practice competently and safely.

These conditions have stimulated intense debate within the health care community as to how to deal with this crisis. The vast majority of frontline nurses – 9 of 10 in Massachusetts and 8 of 10 nationally—who deliver patient care are calling for the implantation of new laws to regulate RN staffing ratios in hospitals.

For its part, the hospital industry has fought any attempt to impose legally enforceable requirements for improving care, and instead has been promoting voluntary solutions and strategies to deal with this crisis. The latest of these is the Magnet Recognition Program, which is run by the American Nurses Credentialing Center (ANCC), a for-profit subsidiary of the American Nurses Association. In fact, the Magnet Recognition Program is yet another in a series of consultant-driven "quality improvement" projects the industry has proposed and implemented in the last decade, including Total Quality Management (TQM), Shared Governance and Patient Focused Care. None of these programs has succeeded in their intended goal, and most resulted in fostering the conditions that have created the crisis nurses and patients now face.

The Magnet Recognition Program confers the designation "Magnet Nursing Services Recognition" on hospitals which are able to pass a lengthy credentialing inspection by a team of surveyors, in very similar fashion to JCAHO's (Joint Commission on Accreditation of Healthcare Organizations) inspection and credentialing process.

Magnet evaluation criteria are based on quality indicators and standards of nursing practice as defined in the ANA's Scope and Standards for Nurse Administrators (1996). The criteria are similar to JCAHO standards. To obtain Magnet status, health care organizations must apply and pay a fee to the ANCC, submit extensive documentation that demonstrates their compliance with the ANA standards, and undergo an onsite evaluation to verify the information in the documentation submitted and to assess the presence of the "forces of magnetism" within the organization.

According to the ANCC, as of July 30, 2004, there were a little over 100 Magnet-designated facilities in the country. Currently, two hospitals in Massachusetts -- Massachusetts General Hospital and Winchester Hospital --have been designated as Magnet facilities, both in late 2003.

Once designated a "Magnet Hospital," the facility then markets itself as a preferred employer of nurses and can use its magnet status as a "seal of approval for quality care." The industry is also seeking to use magnet status as a justification for higher rates of reimbursement from third party payers.

Here in Massachusetts interest in and applications for participation in the Magnet Recognition Program has increased, causing staff nurses inside and outside of the MNA to request MNA's position on the "Magnet" process. Here we present our position on the Magnet process as a concept, as well as provide key principles to help nurses in determining if and how they wish to participate in this or any similar process.

I. MNA Organizational Position on the Magnet Recognition Program

The Massachusetts Nurses Association Board of Directors is opposed to the concept of the Magnet Recognition Program for the following reasons:

Magnet Recognition Is Being Used as a Marketing Ploy to Increase Market Share by Trading on the Trust and Credibility Nurses Have With the Public
One of our most important reasons for opposing the magnet program is that the primary  selling point of the program by the ANCC, and the key motivation for an institution's participation in the process, is to utilize Magnet Recognition as a marketing ploy to garner greater market share, and to do so by trading on the respect and credibility of nurses (particularly staff nurses) in the eyes of the public.

The process is structured around the formation of "Nursing Councils", which give the illusion of shared governance and nurse empowerment, without granting nurses equal power with management and the ability to shape and modify the decisions made through the process. Nurses have no legally

protected veto power in the process, and all decisions are still ultimately left to senior administrators. However, when the final decisions are made, because staff nurses participated in the process, the mere fact of their participation will be used to substantiate and validate the process.

Nurses have been down this road many times before. We believe Magnet Recognition is yet another, top-down process, like TQM, Patient Focus Care, and so many other high priced, consultant-driven programs that provide no real guarantee of quality patient care or for the creation of conditions that will protect nursing practice.

Excellence in Nursing Services Must be a Condition of Licensure
Providing quality nursing care and establishing standards of quality care for nursing services should not be a matter of choice by a particular institution, but should be a basic legal requirement and condition of licensure by the Department of Public Health. All hospitals should be held accountable for having positive patient outcomes. All hospitals should be accountable for providing safe staffing and a satisfactory work environment for its nurses.

Money Spent on Consultants is Better Spent on Direct Patient Care
The Magnet program is another expensive program, requiring thousands of dollars in fees to consultants, and thousands of dollars in staff time. This money would be better spent on improving staffing conditions or on nursing salaries. It is also important to understand just who is behind this program. The Magnet program was created by the American Nurses Association as a profit making venture.  Not only does ANCC collect fees to conduct the Magnet evaluation, it also provides consultants, for a fee, to assist in achieving the designation. The ANA is firmly opposed to nurses' having the right to mandatory RN-to-patient ratios.

Voluntary Credentialing/Accreditation Programs Don't Work
The nursing community has had many years of experience in evaluating the effectiveness of voluntary credentialing programs such as the JCAHO accreditation process. The JCAHO program is universally condemned by nurses as a farce, providing no true evaluation of the quality of care in the hospitals it surveys. In fact, this has been substantiated by two exhaustive governmental reports on the process: one in 1999 by the Inspector General of the United States and another by the Government Accounting Office, which found that many JCAHO accredited hospitals were found to have significant patient safety problems undetected by the surveyors. The Inspector General's report criticized JCAHO because there was too collegial a relationship between the surveyors and the surveyed in the process. We see the same problems being duplicated by the Magnet Recognition Program.

Magnet Recognition Fails to Include any Requirement for Safe RN-to-Patient Ratios
In numerous studies and in every credible survey of nurses, the most important solution to the problem of providing quality patient care and of creating conditions to retaining nursing staff is the need to establish safe, minimum RN-to-patient ratios or, in the absence of minimum ratios, to grant frontline nurses the right to refuse patient assignments that prevent the delivery of quality patient care.

The Magnet Recognition Program provides no specific recommendations for the establishment of safe staffing standards, nor does it grant nurses the protected right to refuse an unsafe patient assignment. The MNA cannot support a program that claims to provide a "seal of approval on quality of care for the public" that does not include a guarantee of safe staffing standards.

In the Unionized Setting, the Magnet Process Undermines the Collective Bargaining Process and True Workplace Democracy
In a hospital where nurses are unionized, the collective bargaining process conducted through the existing labor/management relationship is the established, legally protected forum for addressing all issues impacting nurses' working conditions. Any program that purports to seek and utilize staff nurses' input, any program that proposes changes in policies and practices to boost retention and recruitment of staff without directly dealing with the nurses' elected union representatives undermines the collective bargaining process and nurses' rights. Such decisions can only be decided by the union as a matter of law.  Further, if the hospital is serious about working in partnership with nurses as equals to arrive at standards they are willing to stand behind and truly endorse, then they should be willing to engage in good faith negotiations over those changes and to codify them through enforceable language as part of the union contract.

II. MNA Principles of Participation for Nurses Considering Magnet Recognition
While the MNA, as an organization, is opposed to the Magnet Recognition Program for the reasons provided above, we recognize many non-unionized nurses without self-governance will have limited ability to stop their employer from seeking Magnet status. Other nurses in good faith may already be engaged in this or another process where they believe their efforts and credibility will result in better patient care.

The MNA Board of Directors wanted to provide nurses with some guidance as to key principles for participation in any institutional process that seeks to utilize nurses' expertise and credibility with the public. W e strongly urge nurses to consider these principles prior to their entering into the process. These include:

• Frontline nurses should have the power to select, among themselves, who will represent them in the Magnet or any other process.
• Front-line nurses elected or appointed by their peers to participate in the process must have the right to recommend and approve changes in the criteria for Magnet status based on the needs of their particular institution.
• In a unionized setting, any and all proposals made that impact the working conditions of nurses are subject to review, negotiation and ratification by the union.
• The result of the Magnet process should result in a written, legally binding document that guarantees nurses a voice and a real choice in all decisions impacting their work and obligating the institution to adhere to the standards arrived at for the life of the Magnet Recognition designation—which is four years.
• Nurses participating in the process should have access to all information and materials (i.e. financial documents, consultant's studies, vendor contracts, merger or restructuring plans, etc.) that will assist them in making informed decisions.

The process recognized in the workplace that must adhere to these principles is the employee governance process authorized and protected by law – collective bargaining.